All Reports

Review and correct the processing errors on decisions the Office of Inspector General team identified so that they are compliant with 38 C.F.R. § 4.118 and consistent with the Adjudication Procedures Manual.

Initiate and provide a timeline for revising the “Scars/Disfigurement” disability benefits questionnaire to clearly elicit information needed for claims processors to determine whether subjective reports of scar pain or tenderness are supported by objective evidence, as required, to establish a compensable evaluation for a painful scar under the Adjudication Procedures Manual.

Determine and complete additional actions so that employees understand how to accurately evaluate painful scars under 38 C.F.R. § 4.118 and in accordance with the Adjudication Procedures Manual.

The Chief of Staff and Associate Director for Patient Care Services develop written service-level workflows that outline staff members’ roles in the process to communicate test results to patients, in accordance with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Associate Director requires bathroom and shower emergency pull cords to be present, accessible, and functional, in accordance with the National Fire Protection Association’s NFPA 99 Health Care Facilities Code.

The Chief of Staff develops written workflows for each service consistent with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Chief of Staff develops and implements a standardized process to routinely assess panel size and efficiency, as required by Veterans Health Administration Directive 1406(3), Patient Centered Management Module (PCMM) for Primary Care.

The Director develops and implements a process to meet the seven‑day scheduling requirement in Veterans Health Administration’s Consult Timeliness Standard Operating Procedure.

The Director takes appropriate steps to maintain clean patient care areas and properly manage biohazards, in accordance with Veterans Health Administration Directive 1131, Management of Infectious Diseases and Infection Prevention and Controls Programs.

The Director takes appropriate steps so the facility’s annual assessment for Legionella disease prevention includes the Papillion community living center, as required by Veterans Health Administration Directive 1061(4), Prevention of Health Care-Associated Legionella Disease and Scald Injury from Water Systems.

The Chief of Staff takes the appropriate steps for leaders to assess the facility’s pharmaceutical waste disposal processes and reeducate staff on safe handling and disposal practices, in accordance with the facility’s Regulated Waste Materials Management policy and Pharmaceutical Return, Waste, and Disposal Standard Operating Procedure.

The Chief of Staff and Associate Director for Patient Care/Nurse Executive take the appropriate steps so leaders create service-level workflows that outline staff roles for communicating test results to patients and providers, as required by Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Under Secretary for Health implements corrective actions to ensure discharge instructions for veterans consistently include appointment locations in easy-to-understand language.

The Under Secretary for Health implements corrective actions to ensure discharge instructions for veterans who received inpatient mental health care include the purpose for each medication listed and do not include medical abbreviations.

The Under Secretary for Health implements corrective actions to ensure risk-benefit discussions occur for newly prescribed medications.

The Director takes appropriate action for employees to keep patient care areas clean as required by Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program and clean storerooms as required by Veterans Health Administration Directive 1761, Supply Chain Management Operations.

The Director takes appropriate action for employees to inspect and test all medical equipment as required by The Joint Commission standard PE [Physical Environment] 04.01.01.

The Director takes appropriate action so pharmaceutical waste containers are provided and accessible, and trains employees on container use as required by Veterans Health Administration Directive 1850.06(1), Waste Management Program.

The Director takes appropriate action so employees secure power strips as required by National Fire Protection Association’s Health Care Facilities Code, NFPA 99 and electrical cords are connected to prevent pulling or straining as required by National Electrical Code, NFPA 70.

The Under Secretary for Health considers including high-risk conditions, such as suspected cancer, to the listing of complex/chronic conditions within the administrative portion of the consult tool outlined in the Veterans Health Administration Office of Integrated Veteran Care (IVC) Community Care Field Guidebook.

Facility leaders take appropriate actions so staff maintain a safe and clean environment, in accordance with Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.

The Chief of Staff and Associate Director for Patient and Nursing Services develop service-level workflows that outline responsibilities in the patient notification process and update the facility’s test result communication policy to align with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Chief of Staff and Associate Director for Patient and Nursing Services implement actions based on external peer review data to improve providers’ communication of test results to patients, in accordance with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Director takes appropriate actions so that staff consistently follow the facility’s Legionella prevention plan and achieve and sustain compliance with all applicable requirements in Veterans Health Administration Directive 1061(4), Prevention of Health Care-Associated Legionella Disease and Scald Injury from Water Systems to prevent contamination and maintain water quality, including testing, documentation, and mitigation actions, to protect resident safety in the community living center.

The Director develops and implements a written policy for communicating test results that aligns with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Chief of Staff and Associate Director for Patient Care Services develop written service-level workflows that align with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Chief of Staff and Associate Director for Patient Care Services take corrective actions to address unfavorable trends in the communication of test results in accordance with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Director evaluates the Healthcare Delivery Board and takes actions when warranted to provide proper oversight of clinical care quality in accordance with Joint Commission standards Medical Staff 16.01.01 and Leadership 11.01.01.

The Chief of Staff and Associate Director for Patient Care Services take appropriate actions to develop written service-level workflows that describe team members’ roles in the process of communicating test results, per Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Chief of Staff and Associate Director for Patient Care Services review performance measure data for test result communications and take corrective action when they identify noncompliance with communicating abnormal test results within seven days, per Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Director performs a comprehensive safety risk assessment of enclosed walkways and implements necessary corrective actions to mitigate slip hazards, in accordance with Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.

The Director takes appropriate actions for staff to regularly identify and remove expired supplies in all areas outside standard supply rooms to comply with Veterans Health Administration Directive 1761, Supply Chain Management Operations.

The Veterans Integrated Service Network Director monitors the facility’s processes to prevent repeat environment of care findings and takes any needed actions to meet the requirements of Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.

Update VA’s enterprise data strategy and spatial data strategy and other related policy documents to align with the goals and objectives of the National Spatial Data Infrastructure strategic plan for 2025–2035.

Update VA directives, handbooks, and standard operating procedures to ensure they are current and aligned with operational goals related to geospatial functions and responsibilities.

Develop a comprehensive plan to ensure the Office of Data Governance and Analytics and other related offices have the necessary resources to fulfill the responsibilities of effective geospatial data collection, production, and stewardship regarding related activities of the covered agency and, as necessary, support the activities of the Federal Geographic Data Committee.

The Director takes appropriate actions so leaders update the facility’s policy for communicating test results to include how providers communicate life-changing results to patients at high risk for suicide, as required by Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Chief of Staff and Associate Director for Patient Care Services develop workflows that describe how each team member participates in the process to communicate test results, in accordance with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Director takes appropriate action so staff update the facility’s test result communication policy to align with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Chief of Staff and Associate Director for Patient Care Services develop workflows that describe staff members’ roles in the process of communicating test results to providers and patients, as required by Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Director takes appropriate action so staff conduct a risk assessment to identify areas that need temperature and humidity monitoring and implement changes accordingly to comply with Veterans Health Administration Directive 1761, Supply Chain Management Operations.

The Director takes appropriate action so staff secure liquid nitrogen tanks, maintain unobstructed access to exits, conduct a risk assessment on safe liquid nitrogen storage options to increase safety, and implement changes accordingly to align with the National Fire Protection Association’s Compressed Gases and Cryogenic Fluids Code NFPA 55, Health Care Facilities Code NFPA 99, and Code of Federal Regulations title 29, section 1926.34.

The Director takes appropriate action so staff improve processes to prevent repeat environment of care findings as required by Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.

The Director takes appropriate actions throughout the facility to support patient and visitor navigation, in alignment with VA Integrated Wayfinding & Recommended Technologies.

The Director takes appropriate steps to repair exterior walkways and mitigate identified safety hazards, in accordance with Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.

The Director takes appropriate actions to improve the cleanliness, safety, and maintenance of patient care areas, in accordance with Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.

The Director implements measures to keep exit pathways free of obstructions, as required by the Joint Commission Standards Manual, Life Safety, 02.01.20.

The Director requires the Comprehensive Environment of Care Committee to monitor corrective actions for identified findings and report on the sustainability of improvements, in accordance with Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.